At Blue MountainWellness, we care about you as a person. We are NOT here to judge. We are here to guide and support you. Our path to work together for sensible, maintainable, weight loss begins with honestly filling out this form. We are excited to start that journey with you!

Personal Contact Information

First Name *

Last Name *

Address *

City *

State *

Postal code *

Phone *

Email *

Today's Date *

Patient Gender *

Date of birth *

Height *

Starting Weight *

Marital Status *

Marital Status

Occupation *

How did you hear about us? *

How did you hear about us?

General Health and Wellness History

Are you currently under the care of a physician? *

Are you currently under the care of a physician?

Are you taking any medications? *

Are you taking any medications?

If yes, please specify the medications you are taking

Personal Health: (Check all that apply) *

Personal Health: (Check all that apply)

Has your doctor advised you to lose weight? *

Has your doctor advised you to lose weight?

Do you have any dietary restrictions? *

Do you have any dietary restrictions?

If Yes, please explain any dietary restrictions? *

How often do you exercise? What type of exercise?

Do you feel stressed? *

Do you feel stressed?

If yes, please explain how you feel stressed?

Does your weight problem cause physical pain? *

Does your weight problem cause physical pain?

If Yes, explain how your weight problem cause physical pain?

Average Hours of Sleep per night *

Average Hours of Sleep per night

What else is there about either your history or current condition that you feel you would like to tell us. *

Diet Information and History

List any food aversions and/or foods you don’t eat *

What have you done in the past to lose weight? How long ago? How successful or unsuccessful were you? *

Are you embarrassed by your weight or does it limit your desire to participate in activities?

What is your biggest obstacle to weight loss? *

Psychological Impact of Your Weight Relationship with Food

Does your weight problem make you physically uncomfortable? *

Does your weight problem make you physically uncomfortable?

If yes, describe how your weight problem make you physically uncomfortable

Do you feel that food controls you? *

Do you feel that food controls you?

Does being overweight and unhealthy limit your activities? *

Does being overweight and unhealthy limit your activities?

Do you binge eat? *

Do you binge eat?

If yes, what do you binge eat?

Do you suffer from uncontrollable cravings? *

Do you suffer from uncontrollable cravings?

If yes, what do you crave?

Do you eat because of your emotions? *

Do you eat because of your emotions?

Do you eat between meals? *

Do you eat between meals?

Personal Goals

Please answer the following questions honestly so we can do our best to help you reach your goals. Check ALL areas of treatment that interest you: *

Please answer the following questions honestly so we can do our best to help you reach your goals. Check ALL areas of treatment that interest you:

Does your family support your weight loss efforts? *

Does your family support your weight loss efforts?

What do you consider to be your ideal weight? *

How much weight do you want to lose? *

Signature Date *

To what extent are you willing to commit to achieving better health? *

To what extent are you willing to commit to achieving better health?

I understand that my entire patient history will remain completely confidential and will not be released without express written consent from me. *

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